Introduction of a Dedicated Admissions Nurse to Improve Access to Care for Surgical Patients

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Morris Elliott
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1 Introduction of a Dedicated Admissions Nurse to Improve Access to Care for Surgical Patients Editor s Note: In Introduction of a Dedicated Admissions Nurse to Improve Access to Care for Surgical Patients Hamilton Health Sciences Centre piloted a dedicated admissions nurse who could facilitate the transfer of patients into the organization. Using a series of process improvements along with this new role, the introduction of the Dedicated Admissions Nurse resulted in a 28% reduction in average length of stay in post anesthetic care unit (PACU) for Ward E2 patients from the time they were identified as ready for transfer and a 15% reduction in average wait time in the emergency department. All of the Registered Nurses (RNs) surveyed felt that their workload for admissions-related tasks was reduced and that all RNs surveyed in PACU agreed with the statement: The Dedicated Admissions RN role has improved patient flow related to transferring patients to E2. Contact: Ivan Yuen yuen@hhsc.ca Authors: Yuen, I., BASc, MSc (candidate), Quality Specialist, Quality Patient Safety and Clinical Resource Management Program (QPSCRM) Collerman, A., RN, BScN, Clinical Manager, Surgical Oncology Ward Manktelow, B., RN, Dedicated Admissions Nurse/Charge Nurse, Surgical Oncology Ward Harrow, D., RN, Charge Nurse, Surgical Oncology Ward Evans, W.K., MD, FRCP, President, Juravinski Cancer Centre Potvin, C., RN, BScN, MBA, Director, Surgical and Radiation Programs and Site Administrator, Henderson/Juravinski Cancer Centre Metham, S., BComm, MBA, Manager Quality, QPSCRM Henderson, N., Quality Specialist, QPSCRM Taylor, S., BScN, MBA, Senior Consultant, QPSCRM VanKuren, L., BSc, CHIM, Information Controller, Decision Support Services

Using a series of process improvements along with this new role, the introduction of the Dedicated Admissions Nurse resulted in a 28% reduction in average length of stay in post anesthetic care unit

2 Purpose: Context: Resources: Source of resource: Population group: Patient flow entry and end points: Description/ approach: Tools and tactics: To ensure that surgical oncology patients have timely access to appropriate care, a Dedicated Admissions RN role was created on Ward E2. The role provides a single point of contact for the various admission sources of E2 patients, and facilitates earlier transfers through coordinating and expediting the necessary resources. The role was studied to determine whether it had a positive effect towards decreasing length of stay and providing earlier and increased access to care for patients. The creation of the role provided opportunities to redesign workflow for clinicians on the unit and identify barriers to access to care. There is a need to prioritize and facilitate transfers of patients admitted in the emergency department (ED) to the surgical oncology inpatient unit (Ward E2), and to facilitate the transfer of patients ready to leave the post anesthetic care unit (PACU). There is also a need to determine the appropriate level of care for patients, where healthcare services could be provided on an outpatient basis, and inpatient admissions may be avoided. In 2004, the Advisory Board stated that advantages of having a dedicated admissions nurse include: Easing the burden of new patient processing; Decreasing workload for unit staff; Increased patient satisfaction; and Minimizing unit reluctance to accept new patients. i 1 FTE RN position (or approximately 1955 nursing hours). Support of Quality, Patient Safety & Clinical Resource Management Program in application of quality improvement tools and methodology. Support of Decision Support Services in acquisition of evaluation data. Leadership support provided by Henderson Site Patient Flow Innovation and Learning Steering Committee. The pilot period (duration: 6 months) was funded through the Ministry of Health and Long Term Care Late Career Nurse initiative. Since the pilot, the funding has come from the surgical oncology inpatient unit s operating budget. Population group includes surgical oncology patients in the Henderson Site ED, PACU, Intensive Care Unit (ICU), Coronary Care Unit (CCU), and inpatient unit (Ward E2). Patient flow entry points may be the ED, PACU, ICU, or CCU (sources of admission into Ward E2), and patient flow end point is most likely return to home. The initiative utilized the Hamilton Health Sciences Change and Quality Improvement Model, which was adapted from the IHI Improvement Model (Define- PDSA). The initiative was developed by the unit Clinical Manager and supported by members of the Quality Patient Safety and Clinical Resource Management program and Decision Support Services. The role was piloted for a six month period. Outcome measures and process measures were selected to study the effect of the role in improving access to care. Recommendations were made to adopt the initiative and implement the role permanently in the unit based on results achieved in the pilot. Through collaboration between the Dedicated Admissions Nurse and the Unit Leader, AM Report Guidelines and an Orientation Package for Surgical Residents were created for the surgical oncology inpatient unit.

The role provides a single point of contact for the various admission sources of E2 patients, and facilitates earlier transfers through coordinating and expediting the necessary resources.

3 15. Measurement approach: Impact/ evaluation: Outcome measures were: number of surgical cancellations due to no in-patient bed for on-service patients, percentage of surgeries delayed for on-service patients due to no bed, PACU length of stay for E2 patients, number of admitted on-service patients in ED discharged home directly from ED, and ED length of stay for on-service patients. Control charts were used to determine whether improvements were achieved. Surveys were also conducted with clinicians in the ED, PACU, and Ward E2 to determine their satisfaction with patient flow and workload as a result of the newly created role. The introduction of the Dedicated Admissions RN to Ward E2 resulted in: 28% reduction in average length of stay in PACU for E2 patients from the time they were identified as ready for transfer (see Figure 1) Figure 1 Length of Stay in PACU for surgical oncology patients from the time they were identified as ready for transfer See Table 1 on Tables Page 15% reduction in average wait time in ED for on-service patients transferred to E2 (see Figure 2) Figure 2 Wait Time in Emergency Department for On-Service Patients Transferred to Ward E2 See Table 2 on Tables Page Observation/ Discussion: Critical success factors/ lessons: All RNs surveyed on Ward E2 felt that their workload for admissions-related tasks was reduced and all RNs surveyed in PACU agreed with the statement: The Dedicated Admissions RN role has improved patient flow related to transferring patients to E2. The Unit-Based Dedicated Admissions Nurse role should be considered for areas that have high volume turnover and areas that receive high volumes of flow from more than one area. The role should also considered in context with other system factors that may affect patient flow for a unit seeking to adopt this initiative. Several factors have contributed to the success of this initiative and the positive results that have been evaluated thus far: Unique skill set of Dedicated Admissions RN, combining extensive clinical experience with administrative skills required to coordinate admissions and discharges on E2 Role has become single point of contact for ED and PACU Collaboration with E2 Unit Leader and overall integration with E2 clinical care team Flexibility of Dedicated Admissions RN and adaptability to various demands placed upon role (e.g. fluctuations in surgical cases, support provided to E2 staff in providing patient care) Support from Henderson Patient Flow Innovation and Learning Site Steering Committee and senior leaders

Control charts were used to determine whether improvements were achieved.

4 Limiting factors: Continued efforts to engage physicians will better optimize the Dedicated Admissions Nurse Role. Improved communication of the role to stakeholders will sustain the improvements achieved thus far. Additionally, coordination is needed to formalize a process to expedite diagnostic test for patients flagged for admission avoidance. Furthermore, the working hours of the Dedicated Admissions Nurse may need to be optimized to match patient care demands. Finally, it is important to delineate the Unit Leader and Admission Nurse role responsibilities, identify and promote complimentary overlap, while preventing duplication of work.

Additionally, coordination is needed to formalize a process to expedite diagnostic test for patients flagged for admission avoidance.

5 Table 1 Tables Page I Chart of PACU LOS (in minutes) UCL = Introduction of Dedicated Admissions RN UCL=437.4 Individual Value X-bar = _ X=108 0 LB= Jan Observation May 26 Jun 10 Table 2 Wait Time in ED (in hours) I Chart of Wait Time in ED (in hours) for On-Service E2 Patients UCL = Introduction of Dedicated Admissions RN X-bar = 7.99 UCL=16.33 _ X= LB=0 1-Oct 8-Oct 15-Oct 22-Oct 29-Oct 5-Nov 12-Nov 19-Nov 26-Nov Week 3-Dec 10-Dec 17-Dec 24-Dec 31-Dec 7-Jan 14-Jan 21-Jan 28-Jan 4-Feb 11-Feb 18-Feb 25-Feb 3-Mar 10-Mar 17-Mar 24-Mar i Health Care Advisory Board (2004). Creating an Admissions Nurse Position for Throughput Improvement. The Advisory Board Company: Washington, D.C.

Patients UCL = 18.54 Introduction of Dedicated Admissions RN X-bar = 7.99 UCL=16.33 _ X=6.

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